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Keywords:
buried bumper syndrome, PEG tube, complication
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Introduction:
Percutaneous endoscopic gastrostomy (PEG), first described over 25 years ago in pediatric patients,1 is a minimally invasive method to provide enteral nutrition. Usual indications for placement include malignant obstruction in the oro-nasopharynx,2, 3 cerebral vascular accidents leading to feeding difficulties and aspiration, and head trauma.4-6 It is rarely indicated in patients with a limited life expectancy or severe dementia.7 Overall, PEG tube placement is associated with a low risk of serious complications ranging from 1%-4%, however peritonitis, peristomal wound infection, gastrocolic fistula, perforation, hemorrhage, and hepatic injury have been reported.7 Buried bumper syndrome, an uncommon complication, can lead to abdominal pain, infection and tube malfunction.
Case Report:
42 year old man with stage IV papillary carcinoma of the thyroid seen for severe abdominal pain and serosanguinous drainage at the site of the PEG tube, which had been placed at an outside hospital 14 days earlier. He did not respond to amoxicillin/clavulanate elixir. An abdominal computed tomography was performed to evaluate for an intra-abdominal abscess. No abscess was seen, however the internal bumper of the gastrostomy tube was located within the gastric wall (Figure 1; arrow). Upper endoscopy was performed which revealed a large non-bleeding ulcer with a partially visible internal PEG bumper within it (Figure 2). The external bumper of the gastrostomy tube was loosened. A rat tooth forceps (Olympus Inc. FG-9L/U, Orangeburg, NY) was inserted into the working channel of the endoscope to grasp the “lip” of the internal bumper; the bumper was pulled back into the stomach (Figure 3). Proton pump inhibitor therapy was instituted and he was kept on IV fluids for 48 hours with the gastrostomy tube at gravity drainage. Tube feedings were then resumed at a slow rate and advanced to include total recommended daily calories within the next 3 days. On this regimen, the gastrostomy tube functioned without leakage. The external bumper was positioned so that there was 2cm of play between the external bumper and the skin allowing the internal bumper to move freely thus eliminating the possibility of excessive compression pressure between the internal and external bumpers.
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Discussion
Excessive traction on the gastrostomy tube from an overly tight external bumper can lead to ischemia of the gastric mucosa and wall as well as ischemia of the abdominal wall thus causing necrosis and ulceration. Over time, this will result in external migration of the internal bumper through the gastric and abdominal wall along the PEG tube track. This complication, known as the “buried bumper syndrome”,8-10 is reported to occur in 2.0% to 6.1% of cases.11, 12 Patients often present with abdominal pain, peristomal leakage, skin ulceration, or inability to infuse feeding formula through the tube. Once the internal bumper migrates outwards along the PEG track, the gastric side of the track may close and eventually re-epithelialize with normal appearing gastric mucosa.
Buried bumper syndrome typically becomes apparent after 4 months,13 however 15 days to 7 months have been reported.12, 14 A buried bumper was noted in this patient after only 14 days, which demonstrates that a long interval is not required for pressure necrosis and subsequent migration of the internal bumper to occur.
Various endoscopic and non-endoscopic techniques have been described to remove the embedded bumper. The simplest technique is to apply external traction on the PEG tube without a skin incision.13 Venu et al described a technique using the dilator end of a new PEG tube; the technique is the same as for initial placement of a PEG but the guide wire was passed through the embedded tube resulting in simultaneous removal and replacement of the embedded PEG tube.15 A needle knife has been used in some cases to make radial incisions over the embedded PEG to expose the internal bumper so as to remove it using a rat tooth forceps.12 If the internal bumper is visible endoscopically, a snare or forceps can be used to reposition the bumper. In some cases, external incision or surgical intervention may be required.
Since the initiating event is thought to be gastric ischemia and ulceration secondary to an excessively tight external bumper, it has been recommended to allow a 1.5 cm gap between the external bumper and the skin to reduce the risk of a buried bumper.13 Others have recommended twirling and pushing the PEG tube in and out of the track 1 cm during daily gastrostomy care prior to the replacement of the external bumper to its original position.16 The inability to push in or rotate the PEG tube may indicate a buried bumper and should be evaluated promptly.
It has been our practice to loosen the external bumper by two centimeters the day after the PEG placement. Following this regimen, we have not seen this complication.
It is important, therefore, for physicians to be aware of this uncommon but preventable complication associated with PEG tubes.
References:
1. Gauderer MW, Ponsky JL, Izant RJ, Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. Dec 1980;15(6):872-875.
2. Amann W, Mischinger HJ, Berger A, et al. Percutaneous endoscopic gastrostomy (PEG). 8 years of clinical experience in 232 patients. Surg Endosc. Jul 1997;11(7):741-744.
3. Chandu A, Smith AC, Douglas M. Percutaneous endoscopic gastrostomy in patients undergoing resection for oral tumors: a retrospective review of complications and outcomes. J Oral Maxillofac Surg. Nov 2003;61(11):1279-1284.
4. Akkersdijk WL, Roukema JA, van der Werken C. Percutaneous endoscopic gastrostomy for patients with severe cerebral injury. Injury. Jan 1998;29(1):11-14.
5. Harbrecht BG, Moraca RJ, Saul M, Courcoulas AP. Percutaneous endoscopic gastrostomy reduces total hospital costs in head-injured patients. Am J Surg. Oct 1998;176(4):311-314.
6. Klodell CT, Carroll M, Carrillo EH, Spain DA. Routine intragastric feeding following traumatic brain injury is safe and well tolerated. Am J Surg. Mar 2000;179(3):168-171.
7. Loser C, Aschl G, Hebuterne X, et al. ESPEN guidelines on artificial enteral nutrition--percutaneous endoscopic gastrostomy (PEG). Clin Nutr. Oct 2005;24(5):848-861.
8. Behrle KM, Dekovich AA, Ammon HV. Spontaneous tube extrusion following percutaneous endoscopic gastrostomy. Gastrointest Endosc. Jan-Feb 1989;35(1):56-58.
9. Foutch PG, Woods CA, Talbert GA, Sanowski RA. A critical analysis of the Sacks-Vine gastrostomy tube: a review of 120 consecutive procedures. Am J Gastroenterol. Aug 1988;83(8):812-815.
10. Klein S, Heare BR, Soloway RD. The "buried bumper syndrome": a complication of percutaneous endoscopic gastrostomy. Am J Gastroenterol. Apr 1990;85(4):448-451.
11. Braden B, Brandstaetter M, Caspary WF, Seifert H. Buried bumper syndrome: treatment guided by catheter probe US. Gastrointest Endosc. May 2003;57(6):747-751.
12. Ma MM, Semlacher EA, Fedorak RN, et al. The buried gastrostomy bumper syndrome: prevention and endoscopic approaches to removal. Gastrointest Endosc. May 1995;41(5):505-508.
13. Gencosmanoglu R, Koc D, Tozun N. The buried bumper syndrome: migration of internal bumper of percutaneous endoscopic gastrostomy tube into the abdominal wall. J Gastroenterol. 2003;38(11):1077-1080.
14. Frascio F, Giacosa A, Piero P, Sukkar SG, Pugliese V, Munizzi F. Another approach to the buried bumper syndrome. Gastrointest Endosc. Mar 1996;43(3):263.
15. Venu RP, Brown RD, Pastika BJ, Erikson LW, Jr. The buried bumper syndrome: a simple management approach in two patients. Gastrointest Endosc. Oct 2002;56(4):582-584.
16. Boyd JW, DeLegge MH, Shamburek RD, Kirby DF. The buried bumper syndrome: a new technique for safe, endoscopic PEG removal. Gastrointest Endosc. May 1995;41(5):508-511.
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